Headquarters BC Care Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this newly registered service. This key question has been rated Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.
Staff were not aware of the culture or vision of the service and were unable to describe what this meant in practice. They reported enjoying their work and felt the provider managed the service well, which was positive. However, none of the staff could give examples of how they contributed to achieving this in their day-to-day roles.
At the time of the assessment, the provider was unable to demonstrate how the culture, vision, and values of the service were being fully embedded. This was largely due to the absence of regular staff meetings, supervisions, spot checks, and competency assessments, which limited opportunities to communicate and reinforce expectations consistently across the team. As a result, there was no clear shared direction, and staff practices were not consistently aligned with the service’s intended values.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.
It was clear both the registered manager and the nominated individual were committed to providing a good service and ensuring people were cared for safely, and this dedication was acknowledged. However, our review identified areas where leadership and oversight were not fully effective, which impacted the service’s ability to operate safely and consistently.
Systems and processes to monitor quality, safety, and compliance were not fully embedded, making it difficult to have a clear overview of the care being delivered. There was also evidence of gaps in knowledge and understanding in key areas of regulatory compliance, particularly in relation to risk assessment, driving continuous improvement, and ensuring the service operated in line with all requirements.
As a result, the service was unable to demonstrate their leadership consistently ensured safe, effective, and well-led care. Strengthening governance, oversight, and regular monitoring is required to provide assurance people are receiving care that is safe, effective, and well-led, and to translate the commitment of the leadership into practice.
 

People did not always feel they could speak up and that their voice would be heard.
During the assessment, it was evident staff had not actively used the Freedom to Speak Up processes and were also unable to provide examples of when they had raised concerns or suggested improvements. Most staff were not familiar with the speak up policy and could not explain how it would work in practice, indicating a lack of awareness and confidence in using this route.
Without a clear understanding of the policy, staff may not have felt empowered to escalate concerns, and important issues could go unreported. This includes areas such as care practice, medication management, or safeguarding, where timely reporting is essential for the safety and well-being of people using the service.
There were no records of concerns being raised, formally or informally, and no evidence that staff had been encouraged to use the policy during supervision or other forums. We saw no evidence meetings with care staff were not taking place. Overall, this suggests the culture of speaking up has not yet been fully embedded, and staff may not feel supported to raise issues safely.
 

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.
Staff recruitment was fair, and the service had employed staff from different ethnic backgrounds and those who spoke multiple languages to meet the diverse needs of people using the service. This demonstrates some commitment to equality at the recruitment stage.
However, our assessment identified shortfalls in how equality was promoted once staff were employed. While some efforts were made to support staff communication with people using the service, there was inconsistent access to training, supervision, and involvement in service development. Staff were not consistently aware of policies, procedures, or the culture and vision of the service. Where staff had a diverse health need, adjustments were not in place to support them at work.
These gaps indicated staff did not consistently have equal opportunities to develop, receive support, or contribute fully to the service. As a result, workforce equality is not yet fully embedded in practice.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
While it is clear the provider and their team were committed to running the service, our review highlighted significant gaps in governance and oversight. Beyond care plan and risk assessment audits, there were no formal monitoring tools or systems in place to review and drive improvements across the service. Feedback from people and relatives was collected, but there was no process to collate or analyse it for themes, meaning opportunities to learn and improve may be missed.
There was no standardised documentation to capture safeguarding concerns, accidents, incidents, or medication audits. Without these, the service could not be effectively monitored or assured to be safe and well-led. Staff recruitment files, training, supervision, and spot checks had not been audited, and there was no schedule for ongoing review. This limited the provider’s oversight of workforce development, compliance, and performance.
Although the Statement of Purpose set out that the service would deliver care that was accurate, holistic, and responsive to individual needs, these standards were not yet embedded in practice. For example, services such as palliative and end-of-life care were referenced, but staff had not received training in these areas. Similarly, policies on medication audits outlined expectations, including maintaining audit trails and scheduled checks, but these had not been implemented. MAR and TMAR charts were missing, and high-risk medications were not consistently assessed, leaving gaps in safety and oversight.
Previous action plans and management meeting notes indicated steps were planned to address documentation, audits, and training, but these had not been fully achieved. There remained limited awareness by the registered manager of which audits were required to meet regulatory expectations. Overall, these gaps meant there was insufficient assurance the service was being consistently monitored, improved, or operating in line with regulatory requirements.
Governance systems needed urgent strengthening to provide robust oversight, ensure compliance, and drive continuous improvement.
The provider has taken some immediate action following the feedback and has started to create templates and schedules for audit purposes. These were in their infancy and had not been tested for efficacy in the service.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
During the assessment, we saw limited evidence the service worked in partnership with other agencies or supported people to engage with their local communities. Care staff did not routinely support people to access local community groups or activities as part of their care package, which limited opportunities for social inclusion and community engagement.
Policies and business plans referenced the importance of partnership working and collaborative development; however, there was limited evidence these principles were being implemented in practice. The lack of engagement with people, staff, and partner organisations reduced opportunities to build meaningful partnerships, share learning, and improve the quality and responsiveness of care.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.
During the assessment, we found limited evidence the service had learned from previous feedback, audits, or reviews. Apart from a local authority audit, there was no clear evidence findings or recommendations had been acted on or embedded into everyday practice. Many of the same shortfalls identified in the earlier local authority review were still present at the time of this assessment.
There were no effective systems in place to review or evaluate performance. Without these checks, the provider cannot identify where improvements are required or monitor whether any actions taken have been effective.
The service lacked a clear strategy or plan to drive continuous improvement.